Nurses and other expenses

I had a stressful day on Friday that I’d rater forget about, related to extraneous events that I just can’t deal with at the moment. I’ve posted a happy picture of me and a friend swimming last May because it makes me smile.

Luckily, or not, I’ve been diverted by the nurse shortage, which is of course due entirely to events outside the government’s control, and for which their policies and short-termist swingeing cuts cannot possibly be held accountable. Oh, and they’ve been saying, ad nauseum in answer to any number of questions in parliament, just how many ‘extra’ nurses (doctors, paramedics) there are since they started running the show.

Top of Hunt’s list of reasons for the NHS’s staffing problems, is the rising bill associated with fed up staff whose pay and terms and conditions have been eroded significantly since 2010. These staff, many of whom had worked for the NHS for decades, suddenly started to up sticks and display their greed and lack of compassion and vocation by working via private agencies instead of the NHS.

Hunt doesn’t like this. I thought that was how the great god Market was supposed to operate, Jeremy? Otherwise, why are you privatising NHS Professionals? This is the public, in-house staffing agency which makes a profit for the taxpayer. Why, you could even develop it, drive those agency costs down with another nice bit of enforced competition (see Health and Social Care Act for how that works, though it is rather expensive at £5billion a year from the NHS budget just for competitive tendering). I’m beginning to wonder about Hunt’s brain. Surely blind adherence to dogma and an utter disregard for logic precludes such high office? Hunt is certainly having the kind of effects on the NHS that his tumour namesake continues to exert my own life. The things he’s made me do.

The nurse shortage was highlighted by a newspaper report the other day and it’s a key area of concern not least bearing in mind Hunt’s inexplicable decision to stop nursing degree bursaries and replace them with tuition fees and loans. But the whole story is far more shocking than that.

This report raises a host of relevant issues. The Migration Advisory Committee has recommended that nursing should remain on the shortage occupation list allowing non-EU nationals to be recruited from abroad. It also argues that that the Department of Health (DH) and the NHS failed, with no good reason other than the perceived need to save money, to create enough nurse training places.

It’s estimated that 9.4% of nursing places in England are vacant; and there were 17% cuts to nursing training places under the Coalition government which was a “significant contributing factor” to the current shortage.

The NHS training body Health Education England wanted to commission 3,000 nurse training places in 2016/17. But as a result of “funding constraints” it only commissioned 331 – one tenth of what was needed.

The MAC report concludes:

“It is clear to us that the current shortage of nurses is largely of the health, care and independent sectors’ own making. They did not learn the lessons from the late 1990s/early 2000s when a similar shortage (and reliance on foreign nurses) occurred. Almost all of these issues relate to, and are caused by, a desire to save money. But this is a choice, not a fixed fact. The Government could invest more resources if it wanted to.”

Then a quote from a Department of Health spokesperson:

The Department of Health is “delivering on our plan to train more home-grown nurses”.

What? Could anyone in possession of any of the facts, or indeed a functioning brain, say anything more utterly stupid? It’s no wonder everyone was asleep till the budget woke them up.

Unfortunately, yes, they could. I’m not even going to let you guess who said it:

Hunt in the BMJ: “We’re reforming the funding of nurse training in order to make sure we can afford to train more nurses.”

I suppose he’s referring to his aforementioned plan to replace bursaries for nursing training with loans and tuition fees; bursaries that allow many older people with valuable life experiences to train as nurses, at a time of recruitment crisis and shortages. A policy that will not only actively discourage, but will effectively prevent, many of these people who have families and limited financial resources from training as nurses Hunt has also acknowledged that staff planning has been lacking in the NHS for decades. Yes, it has. So at what point since 2012 when you took over as Secretary of State for Health did you consider actually doing something about it Jeremy? Bravo Mr Hunt indeed.

And behind all of this of course is Mr Hunt’s big push on safety. Safe staffing involves having enough suitably qualified staff, and the Francis and Berwick reports into the Mid-Staffs failures specifically address this concern and recommends NICE – an independent body – to undertake the review. Jeremy liked this, because it allowed him to batter nurses over the head with their lack of compassion and vocation, and their silly pretensions at understanding how to manage the complexities of modern medicine, surgery and technical equipment when they’d be far happier floating up and down with lamps and starched hats, porting flannels with which to transfer pathogens onto fevered brows. Except that the actual evidence might result in the need to actually produce real qualified staff rather than imaginary ones and having to pay them to boot, darn it.

Enter NHS England, the body set up to run the NHS after the Secretary of State for Health was absolved of that little responsibility by the Health and Social Care Act (2012), the one that officially made the NHS no more. (You might have missed that too.) They decided, before the Nice report was published to take over responsibility for the research themselves. Now you might wonder about vested interests versus independence, you might wonder about standards of evidence. You might wonder at NHS England’s their lamentable budget and plan to save £22billion more in ‘efficiency’ savings despite the parlous state of NHS trusts’ finances. You might have predicted that the DoH would withold the NICE information under Freedom of Information. But nicely, NICE then decided it was in the public interest to release the information later, and you can see their reasoning here.

There are many examples of government tactics to avoid answering difficult questions; they’ve reached a level where debate is not happening because spin is automatic, it’s reported often without question in the right wing tabloids and broadsheets, misused statistics are stated as fact, significant evidence is buried in favour of cherry picking from often discredited research (the NHS Risk Register has still not been released).

One of the nastier methods involved the Prime Minister’s repeated use of his late son Ivan’s disability as a means of blocking debate on the NHS in parliament because this proved his love for the NHS. The Camerons must have been through hell, and nobody can argue that they didn’t do their very best by Ivan. They didn’t hide him, he was clearly deeply loved. Yet their experiences are always mitigated by wealth, by the ability to set up a converted basement at home to care for their son. Cameron used Ivan as emotional blackmail to get out of answering questions about his intentions for the NHS. The Camerons’ is also not an experience made more harrowing still by the bedroom tax and the government fighting a High Court decision arguing the bedroom tax discriminates against disabled people by challenging some of them in the Supreme Court.

The NHS is an now a collpasing omnishambles, to borrow an ill-fated phrase from an ill-fated leader; one created by government policy over the past fifteen or so years that introduced the internal market (those fundamental conflicts of value systems between the human and the financial again) although Labour at least invested money and our NHS ranked highly among health services in 2012. Since then, the coalition and Tory governments under Cameron have destroyed it. They haven’t asked us what we want, they’ve lied, been caught lying, continued to get away with lying to us and to each other. Many of the staff in the NHS have no idea what the Health and Social Care Act did – which is laid the foundations for privatisation while burying the bodies of pitfalls and costs beneath the foundations of their spin flyover. It’s time for the government to take responsibility and do the job we are paying it to do, while telling us exactly what that is.

Finally, I couldn’t resist adding this piece from Conservative Home in full. I’ll let it speak for itself. At least the author is honest.

Comparisons with the Miners’ Strike of 1984 come naturally when talking about the British Medical Association. But whilst we remember a straight-up confrontation, it was only careful Government planning and an undercurrent of irresistible technological change that made Thatcher’s belligerence viable.

The Government’s dispute with the doctors’ union continues to escalate, with junior doctors preparing to hold the first full walkout in the history of the NHS.Writing in the Daily Telegraph, James Kirkup gives the recalcitrant medics a warning from history. He warns that the BMA is repeating the mistakes of the National Union of Mineworkers, over-estimating the nation’s dependency on their members.

That Britain’s economy could survive without British coal was unthinkable, right up until it wasn’t. Kirkup argues that technological progress and competing models of provision mean that our monolithic state healthcare provider may soon find itself similarly outflanked.

But whilst that might be true, it is by no means certain that we have reached this point now. For all that Arthur Scargill’s attempt to topple Margaret Thatcher is the stuff of legend, it shouldn’t eclipse the fact that there were plenty of miners’ strikes before that final confrontation and the miners won most of them, enjoying public sympathy as they did so.

Jeremy Hunt could end up being a modern-day Margaret Thatcher, bringing truculent trades unionists to heel and unleashing modernity on one of the UK’s totemic industries. Or he could be Edward Heath.

As Simon Jenkins points out in today’s Daily Mail, public support for the NHS is currently bulletproof. This makes it incredibly hard to reform: in fact, the public health lobby have convinced many politicians that it is easier to reform the public than to make a serious attempt to reform public services.

“Cost to the NHS” is thus one of the main pillars of modern drives against smoking and obesity. But setting aside any liberal qualms we might have about that, it isn’t clear that this represents a viable long-term solution.

Anybody who the state ‘saves’ from a tobacco or food-related death will still die of something, and the NHS will pay for it. If that person is forced to live a long life then they will likely end up costing the NHS far more than they would had they died younger – the increasing ability for medical science to prolong our senescence is by far the greatest structural challenge the service faces.

Treating expenditure on smoking and obesity-related health problems as money that can be straight-up saved, without accounting for the inevitable transfer of the burden to other parts of the health budget, is therefore extremely disingenuous.

Assuming that we can’t force people do be so healthy that we can afford the NHS, we’re then still confronted with the need to reform it.

It may be that needless deaths caused by industrial action lead to a dramatic sea change in popular attitudes, but as it stands we’re a long way from a place where “wholesale reform via head-on confrontation” seems likely to work, even as a last resort.

Rather, Conservatives should have a long-term, strategic vision for healthcare reform which involves the piecemeal adoption of decentralisation, liberalisation and modernisation in doses the public will tolerate.

Obviously there are a huge number of things this could involve, and Party policymakers should canvass widely for proposals. But when it comes to tackling the outdated and overweening influence of militant unions in the NHS, here are two suggestions.

In his article, Kirkup mentions “the George Washington University study that estimates 85 per cent of a typical doctor’s work can be done perfectly well by a “physician’s assistant” with a fraction of the training or wages.”

If that is the case, perhaps one way to increase staff supplies in the service – without resorting tocontroversial over-dependence on foreign nurses – would be some form of ‘Territorial NHS’, or Health Service Reserve, modelled on its military counterpart.

Volunteers would receive pay, training, and legal rights to take time out of their ‘civilian’ life to work for so many weeks of the year in the NHS. This shouldn’t be impossible: the Armed Forces reserves already offer recruits the opportunity to train in a huge range of technical skills.

A larger, flexible pool of ‘physician’s assistants’ would reduce the NHS’s dependence on full-time professionals. This would not only ease immediate wage and staffing pressures, but make it easier for management to respond to future shifts in demand.

Like any nationalised industry, one of the major problems facing the health service is its need to predict future demand without the aid of psychics. The long training current staff require makes it impossible to rapidly adjust to unexpected demand (without importing labour, that is.)

A ready pool of capable staff, which can be topped up relatively quickly, could thus plug gaps as they arise and make it easier to do that with British personnel.

Given public affection for the NHS, and the esteem in which its staff are held, there’s no reason to think that recruitment would be impossible.

The other way the Government could clip the BMA’s wings would be to diminish their capacity for strike action.

One could approach this task in at least two ways. The blunt-force approach would be to declare doctors, at least, to be one of the essential professions – such as the police and the military – whose members are forbidden to strike. If the junior doctors keep up their current antics this may well become politically possible.

At a stroke, this would bring the public sector into line with the private by making politically-motivated, industry-wide strikes impossible.

This is because, with sympathy strikes and secondary picketing illegal, trades unions can only call strikes over a specific grievance with an individual employer. In the private sector this has led to conciliatory, service-based unions.

But because all public sectors workers are ultimately employed by the Government, they have been spared the effects of this legislation.

Making hospital trusts independent would not only mean the end of the national strike, it would also yield other benefits. By employing staff on private sector terms such essential and sensible reforms as locally variable and performance-based pay, as well as rational, private-sector pensions, would be as irresistible as they have been in the private economy.

Faced with an incentive to innovate and reduce costs, some trusts may even start to innovate with things like the “production-line” surgical hospitals pioneered by Devi Shetty – channelling the savings into other areas.

It would also mean that in the event of a dispute at any trust, the Government would not be on one side of the table, under political pressure and with the easy out of simply paying up from taxation or borrowing.

One day, the BMA will have their 1984. But it would be complacent to assume that this is it, or that bloody-mindedness alone will bring it about. Conservative strategists owe it to themselves, and to the country, to lay the groundwork properly.

It’s stunning isn’t it? I quite like the bit about letting people die faster rather than trying to save them from their bad habits because we can’t afford it; and the idea of an NHS TA run by incompetent volunteers who will be cheaper – for the plebs only, I suspect.
Oh, and what gives this chap the idea that his insurance isn’t going to be unaffordable?
Was thinking of Mary Poppins earlier; I loved the film as a child, and my favourite part was the bank visit (if you invest your tuppence safely in the bank) followed by feed the birds tuppence a bag… birds won every time.

Really interesting reading. Hadn’t thought about how decentralising employers affects political unity and strike action. Hmm.. schools becoming academies… Thank you Lynne for researching all this enlightening information. Lots of hugs and can you spare some for that cuddly dog. Xxx